The digital divide and health outcomes : a teleretinal imaging study

Ph.D. University of Hawaii at Manoa 2013.Includes bibliographical references.The purpose of this research project was to understand, explore and describe the digital divide and the relationship between technology utilization and health outcomes. Diabetes and diabetic eye disease was used as the real-life context for understanding change and exploring the digital divide. As an investigational framework, a telemedicine intervention in the form of a diabetic eye care program that utilized web-based eye care education and retinal (teleretinal) imaging over the Internet was implemented. Research has shown that minority and underserved populations in which technology has been made available demonstrate improved their health outcomes. The participant population for this study was recruited from a Federally Qualified Health Center that serves a Federal Medically Underserved Area. Data sources included: 1) surveys using the transtheoretical model (TTM), which were used to explore behavior change as a result of the technology intervention; and 2) focus groups to further explore computer and Internet usage, and to further examine how technology impacted health and health outcomes. Results from the TTM surveys revealed statistically significant differences in readiness to change for exercise, carbohydrate counting and smoking cessation over a three-month period. For the measure of daily self-management there was a significant difference in the transition from having no self-management plan to having a plan. There were also significant differences in decisional balance for exercise adoption and carbohydrate counting. Significant changes in TTM-based processes of change were mainly related to social interaction, such as: 1) environmental reevaluation, which addresses the impact of the social environment on behavior; 2) helping relationships, which involves seeking and using social support; and 3) social liberation, which relates to recognizing changes in social norms. Based on the focus group interviews, all participants felt that their study participation had been a positive experience. All focus group participants agreed that the retinal imaging was not invasive and provided little discomfort. Family was a key theme in the use of computers, improving eHealth literacy, and a key influence as a motivator and barrier for health behavior change. Family was also a key factor in the concept of fear being a motivating factor for behavior change. Fear that they did not want to suffer from the complications of diabetes like other family members had experienced. Additionally, social support was confirmed as a key theme as a motivator for behavior change. Barriers to behavior change included the lack of support from family, food, culture and depression. The food culture of the participants was a theme that impacted the participants a great deal: the love for food; the lack of control when it came to eating; and the culturally high-fat foods that were pervasive in their environment. Symptoms of depression were also key barriers: low self-esteem, lack of confidence, and lack of self-motivation. Results also revealed that the lack of computer access and knowledge on use of the technology were the most common barriers in web access. Overall, the study demonstrated that a teleretinal imaging intervention can help to improve health outcomes. The results of this study contribute to the fields of health behavior change, computer literacy, eHealth literacy, and the digital divide in an underserved, predominately Native Hawaiian population in Hawaii